RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00236
BRANCH OF SERVICE:  Army	DATE OF PLACEMENT ONTO TDRL:  20040424
	DATE OF REMOVAL FROM TDRL:  20060714 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Air and Missile Defense Crewmember) medically separated for diabetes mellitus, Type 1.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “diabetes mellitus, type 1” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (hyperlipidemia and hypertension) for PEB adjudication.  The Informal PEB (IPEB) convened on 17 February 2004 and adjudicated “diabetes mellitus, type 1” as unfitting, rated 40%, placing him on the Temporary Disability Retired List (TDRL).  He was revaluated and a second IPEB continued him on the TDRL but the PEB stated “continued to have difficulty with diabetic control of his type 1 and type 2 diabetes mellitus…” changing the diagnosis to both Type 1 and Type 2 diabetes mellitus.  He was reevaluated and a final IPEB convened on 15 May 2006 adjudicating that his condition was now stable and rating his diabetes mellitus, Type 1 at 20%.  The CI requested a Formal PEB (FPEB) which convened on 22 June 2006 affirming the final IPEB rating of 20%.  The CI made an appeal to the FPEB which affirmed the 20% rating and he was then medically separated.  

CI CONTENTION:  The CI contended for his diabetes mellitus 2 condition.  His complete submission is at Exhibit A. 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

Final PEB – 20060622	VA Rating Decision1 - 20040507	
TDRL Placement – 20040217	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
Diabetes Mellitus, Type I	7913	40%	20%	Diabetes Mellitus	7913	40%	20%	
Other MEB/PEB conditions x 2 (Not in Scope)	Other x 1	
RATING:  40% → 20%	RATING:  50% → 40%	
1. Most proximate to TDRL Placement
2. Rating on service treatment record (STR)
3. Rating derived from C&P exam dated 21 July 2006, 7 days post-TDRL removal.

ANALYSIS SUMMARY:  

Diabetes Mellitus, Type 1 Condition.  The STR documented that the CI presented with fatigue, weight loss, polydipsia (excessive thirst), and polyuria (excessive urination).  The preliminary diagnosis was diabetes mellitus, Type 2 (DM2).  It is characterized by hyperglycemia (high blood glucose) and variable degrees of insulin (pancreatic islet hormone produced by beta cells that regulates blood glucose) resistance and insulin deficiency.  The initial management included diet, exercise, and oral anti-hyperglycemic medications.  Further laboratory evaluation suggested diabetes mellitus, Type 1 (DM1).  It is characterized by destruction of pancreatic beta cells leading to an absolute insulin deficiency.  Diabetes mellitus Type 1A (DM1A) is due to autoimmune (immune response against own tissue) destruction of the beta cells (Type 1A).  The diagnosis of DM1A is confirmed by testing for pancreatic islet autoantibodies.  Diagnostic labs confirmed evidence of autoimmunity with two of three tested autoantibodies positive.  The narrative summary (NARSUM) by endocrinology, a month before placement on TDRL, recounted the history and interventions.  The endocrinologist reported that the CI had features of both DM1 and DM2.  He required both insulin therapy to treat insulin deficiency and insulin sensitizing agents to treat insulin resistance.  The CI was treated with long-acting (basal) insulin, short-acting (pre-meal) insulin, and oral insulin sensitizers.  The endocrinologist stated that despite frequent adjustments to his regimen, the CI had achieved a poor to fair level of blood sugar control.  He had been able to function adequately, though sub-optimally, on his regimen of multiple insulin injections, strict dietary attention, and frequent blood glucose monitoring.  The examiner opined that poor control could be a complicating factor if prolonged physical activity, under extreme conditions, was required.  The STR contained no evidence of episodes of ketoacidosis (life threatening elevation of serum acids [ketones], hyperglycemia, electrolyte disturbances, and dehydration) or hypoglycemic (low blood glucose) reactions requiring hospitalizations.  The CI was referred to the PEB and placed on TDRL.

The TDRL evaluation by endocrinology, 26 months after placement on TDRL, recounted the history and interventions.  The CI complained of persistent fatigue, polyuria, polydipsia, and a 10 pound weight loss over 3-4 months.  The CI reported he checked his finger stick blood glucose levels before each meal, followed a diabetes appropriate diet, and exercised routinely.  The CI continued to be treated with long-acting and short-acting insulins and an oral insulin sensitizer.  The physical exam revealed no evidence of the diabetic complications of retinopathy (retinal blood vessel damage), peripheral neuropathy (vascular and metabolic nerve damage), or peripheral vascular disease (diminution or absence of peripheral pulses).  The endocrinologist documented that no complications of diabetes had been reported to date, and he had not required hospitalization for diabetes-related problems.  He stated the CI “… has not been able to improve his glycemic [blood glucose] control over the past year and is expected to require continued close follow-up and management to achieve this.  However, he is very capable of performing a variety of duties, with the exception of those that require prolonged strenuous exercise.”  The examiner documented that the CI worked “… as an instructor for Sentinel Radar with 36-ADA at Ft. Bliss.” and would “… need quarterly visits to an internist or endocrinologist ….”  The diagnosis listed DM1 and the CI was referred to an IPEB.  The IPEB found him unfit and recommended separation with severance pay.  The CI requested an FPEB which affirmed the IPEB rating.  The CI did not concur, made an appeal, and the Board adhered to the original findings and recommendations of the formal hearing.  The Board documented that it “…could not rate your diabetes at 40% for limitation of activities as running and basketball are a part of your routine.”  

The VA Compensation and Pension (C&P) exam, a week after removal from TDRL, recounted the history and interventions.  The CI stated “… that he had some fatigue with some sleeping problems that … slows him down, but not due to his diabetes.”  He denied episodes of ketoacidosis and never requested hospitalization.  The CI reported some mild episodes of hypoglycemia at least twice a week.  He denied neurological symptoms, but occasionally had soreness and a burning sensation to his feet.  The CI had never been diagnosed or received treatment, for neuropathy.  His diabetes did not restrict his daily activities.  The CI continued to be treated with long-acting and short-acting insulins and oral insulin sensitizers.  He reported he saw his primary care physician every three months for his diabetes.  The physical exam revealed no evidence of the diabetic complications of peripheral neuropathy or peripheral vascular disease.  The diagnosis listed DM1 with no evidence of complications.

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered its rating recommendation at the time of placement on TDRL.  The informal PEB rated the DM1 at 40% (VA code 7913; diabetes mellitus).  The PEB cited significant difficulty in gaining adequate control although compliant with insulin injections, dietary control, oral medications, and activity restrictions.  The VARD, 3 months after placement on TDRL, cited service medical records and rated the DM1 at 40% (7913).  The VARD cited difficulty in gaining adequate control, compliant with insulin injections, dietary control, oral medications, and activity restrictions, and no diabetic retinopathy.  While the initial diagnosis was DM2, based upon the degree of insulin resistance, the diabetes mellitus was better characterized as DM1, because of positive autoantibodies and insulin deficiency.  Board members agreed there was no evidence of ketoacidosis or hypoglycemic episodes requiring hospitalizations, twice a month visits to a diabetic care provider, or complications to support a 60% rating.  While requiring insulin and restricted diet were established, there was no evidence of medically prescribed regulation of activities to support a 40% rating.  Though the NARSUM endocrinologist opined that “Poor blood sugar control would be a potential complicating factor if periods of prolonged physical activity under extreme conditions would be required of this patient,” he did not specify restrictions on activities or conditions.  The characteristics of the 20% rating (requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet) were more consistent with the CI’s overall clinical picture.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudications for the DM1 condition at the time of placement on TDRL.

The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The sole basis for the Board’s permanent disability recommendation is the optimal VASRD rating for disability at the time the CI is permanently separated at removal from TDRL.  The FPEB, 28 months after placement on TDRL, decreased the rating of the DM1 condition from 40% to 20% (7913).  The PEB cited management with insulin injections, oral medications, restricted diet, glucose self-testing, regular aerobic exercise (running 2-3 miles three times a week and playing basketball), stable suboptimal labs, no interval hospitalizations, and no clinical signs of vasculitis, neuropathy, or retinopathy.  The VARD, citing the C&P exam aweek after removal from TDRL, decreased the rating of the DM1 condition from 40% to 20% (7913).  The VARD cited insulin, restricted diet, no requirement for regulated activities; condition did not restrict activities, no ketoacidosis, and a history of mild hypoglycemia twice a week without hospitalization.  Board members agreed there was no evidence of ketoacidosis or hypoglycemic episodes requiring hospitalizations, twice a month visits to a diabetic care provider, or complications to support a 60% rating.  While requiring insulin and restricted diet were established, there was no evidence of medically prescribed regulation of activities to support a 40% rating.  The TDRL evaluation endocrinologist did not specify restrictions on activities and opined “… he is very capable of performing a variety of duties, with the exception of those that require prolonged strenuous exercise.”  The C&P examiner, a week after removal from TDRL, opined that “His diabetes did not restrict his daily activities.”   The characteristics of the 20% rating were more consistent with the CI’s overall clinical picture.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudications for the DM1 condition at the time of removal from TDRL.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the DM1 condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at TDRL placement.  In the matter of the DM1 condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at TDRL removal.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140103, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXX, AR20160002090 (PD201400236)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA